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22 Cards in this Set
- Front
- Back
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What is a Change-of-Shift report?
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a report given to nurses on the next shift.
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Define a Chart.
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A chart is a formal, legal document that provides evidence of a client's care.
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Define Charting.
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Charting is the process of making an entry on a client's record.
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Define CBE.
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(CBE) is Charting By Exception- a documentation system in which only significant findings or exceptions to norms are recorded.
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What is another name for "client record"?
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Chart
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Define Discussion.
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Discussion - an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
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What are some synonym for documenting?
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Charting, Recording.
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What is a Flowsheet?
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A flowsheet is a record of the progress of a specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form.
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A method of charting that uses key words or foci to describe what is happening to the client is known as what?
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Focus charting
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Define Kardex.
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Kardex is the trade name for a method that makes use of a series of cards to soncisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date.
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What do we call a descriptive record of client data and nursing interventions, written in sentences and paragraphs?
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We this Narrative charting.
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What is PIE?
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PIE is an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions.
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What is POMR?
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POMR is an acronym that stands for Problem Oriented Medical Record.
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Describe POMR.
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In POMR data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information.
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What is a synomyn for POMR?
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A syn. for POMR is POR shich stands for Problem-Oriented Record.
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Define Progress notes.
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Progress notes are chart entries made by a variety of methods and by all health professoinals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes.
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What is a Record?
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A record is a written communication providing formal, legal documentation of a client's progress.
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Define Recording.
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the process of making written entries about a client on the medical resord.
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Describe a good Report?
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whether oral or written, it should be concise, including pertinent information but no extraneous detail
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What is SOAP besides something we use to wash our hands with?
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An acronym for a charting method that follows a recording sequence of Subjective data, Objective data, Assessment, and Planning.
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What type of recording is done where each person or department makes notations in a separate section or sections of the client's chart?
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Source'oriented record.
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What is a variance?
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A variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame.
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